Johannes Leitgeb

Severe Traumatic Brain Injury in Austria V: CT findings and surgical management

ZusammenfassungZIEL: Das Ziel dieser Arbeit ist es, CT-Befunde und chirurgisches Management von Patienten mit schwerem Schädel-Hirn-Trauma (SHT) in Österreich darzustellen. PATIENTEN UND METHODEN: Es standen Datensätze von 415 Patienten zur Verfügung, die von 5 österreichischen Zentren in die Studie inkludiert worden waren. Analysiert wurden Inzidenz, chirurgisches Management und Behandlungsergebnis unterschiedlicher intrakranieller Läsionen, sowie das Behandlungsergebnis von Patienten mit/ohne chirurgischer Intervention und mit/ohne Hirndruckmessung. Für die erste Analyse wurde die Patienten je nach dem CT-Befund insgesamt 16 Gruppen zugeordnet. Für die zweite Fragestellung wurden die Patienten in 4 Gruppen (mit/ohne Operation jeweils mit/ohne Hirndruckmessung) eingeteilt. RESULTS: Das mittlere Alter betrug 48,9 Jahre; das Verhältnis von Männern zu Frauen betrug 299:116. Die häufigstenisolierten Läsionen waren Kontusionen (CONT) und diffuses Ödem. Kombinierte Läsionen waren viel häufiger; die häufigsten Kombinationen waren CONT plus Subarachnoidalblutung (SAH) mit und ohne Subduralhämatom (SDH). 276 (66,5%) Patienten wurden operativ behandelt. Osteoplastistische Operationen (OPS; n = 221) wurden häufiger durchgeführt als osteoklastische (OCS; n = 91) und dekompressive Eingriffe (DEC; n = 15). Die Intensivstations(ICU)-Mortalität betrug 29,7% für operativ versorgte Patienten; bei konservativ behandelten Patienten lag diese etwas höher (33,1%). Die ICU-Mortalität von Patienten mit SDH war nach OCS niedriger (18,8%) als nach OPS (36,0%). Patienten die eine Hirndruckmessung erhielten, jedoch keine sonstige chirurgische Therapie benötigten, hatten die niedrigste 90-Tage Mortalität (17,5%). SCHLUSSFOLGERUNGEN: Hirndruckmessung scheint sowohl chirurgisch versorgten wie auch konservativ behandelten Patienten Vorteile zu bringen. Bei Patienten mit SDH, die operativ versorgt wurden, fand sich ein signifikant besseres Ergebnis. Bei Patienten mit SDH war das Ergebnis nach osteoklastischer Operation signifikant besser als nach osteoplastischer Operation.SummaryOBJECTIVES: The aim of this paper is to describe CT findings and surgical management of patients with severe traumatic brain injury (TBI) in Austria. PATIENTS AND METHODS: Data sets from 415 patients treated by 5 Austrian hospitals were available. The analysis focused on incidence, surgical management, and outcome of different types of intracranial lesions, and outcome of surgical interventions with and without monitoring of intracranial pressure (ICP). For the first analysis we assigned the patients to 16 groups based on the type of lesion as evaluated by CT scan. For the second analysis we created 4 groups based on surgical treatment (yes/no) and ICP monitoring (yes/no). RESULTS: The mean age was 48.9 years with a male to female ratio of 299:116. The most frequent single lesions were contusions (CONT) and diffuse brain edema. Combined lesions were far more common than single lesions; the most frequently observed combinations included CONT and subarachnoid hemorrhage (SAH) with or without subdural hematoma (SDH). Surgery was done in 276 (66.5%) patients. Osteoplastic surgery (OPS; n = 221) was the most common method followed by osteoclastic surgery (OCS; n = 91) and decompressive craniectomy (DEC; n = 15). ICU mortality was 29.7% for all patients who had any kind of surgery, which was lower than that of patients who were treated non-operatively (33.1%). The ICU mortality of patients with SDH was lower with OCS (18.8%) than with OPS (36.0%). Patients who received ICP monitoring but did not require surgery had the lowest 90 day mortality (17.5%). CONCLUSIONS: ICP monitoring seems to be beneficial in both operatively and non-operatively treated patients with severe TBI. Patients with SDH who were operated on had significantly better outcomes. In patients with SDH, their outcome after osteoclastic surgery was significantly better than after osteoplastic procedures.

Severity and outcome of traumatic brain injuries (TBI) with different causes of injury

Introduction: Most epidemiological studies and reports have reached a consensus on the leading causes of traumatic brain injury (TBI). Despite the fact that the area of TBI is relatively well studied, reports on differences in severity and outcome of TBI with different causes are lacking. Goal: This paper analyses the differences in severity and in short- and long-term outcome of TBIs with different causes. Method: This study analysed data on 1109 patients with severe TBI by dividing them into three injury-cause groups: ‘traffic-related’, ‘falls’ and ‘other causes’. Severity and outcome was evaluated using chosen direct and indirect indicators. Results: The most severe trauma occurred in the traffic-related group followed by falls and injuries with other causes. On the other hand, patients with traffic-related TBI had the best outcome. Age improves the outcome in the traffic-related group significantly. However, in the multivariate analysis after adjusting for age (and other important predictors including level of care) the odds for favourable long-term outcome stayed significantly higher in the traffic-related group. Conclusions: It is concluded that the causes of TBI should be considered by both clinicians and public health professionals as a lead in prognosis of outcome and policy planning.

The management of bite wounds in children—A retrospective analysis at a level I trauma centre

INTRODUCTION Animal bite wounds are a significant problem, which have caused several preventable child deaths in clinical practice in the past. The majority of bite wounds is caused by dogs and cats, and also humans have to be considered to lead to those extreme complicated diagnosis in the paediatric patient population. Early estimation of infection risk, adequate antibiotic therapy and, if indicated, surgical treatment, are cornerstones of successful cures of bite wounds. However, antibiotic prophylaxis and wound management are discussed controversially in the current literature. In our study, we retrospectively investigated the bite source, infection risk and treatment options of paediatric bite wounds. METHODS A total of 1592 paediatric trauma patients were analysed over a period of 19 years in this retrospective study at a level I trauma centre, Department of Trauma Surgery, Medical University of Vienna, Austria. Data for this study were obtained from our electronic patient records and follow-up visits. In our database, all paediatric patients triaged to our major urban trauma centre have been entered retrospectively. RESULTS During the 19-year study period, 1592 paediatric trauma patients met the inclusion criteria. The mean age was 7.7 years (range 0-18.9), 878 (55.2%) were males and 714 (44.8%) were females. In our study population, a total of 698 dog bites (43.8%), 694 human bites (43.6%), 138 other bites (8.7%) and 62 cat bites (3.9%) have been observed. A total of 171 wounds (10.7%) have been infected. Surgical intervention was done in 27 wounds (1.7%). CONCLUSION Gender-related incidence in bite wounds for dog and cat could be detected. Second, our findings for originator of bite wounds reflect the findings in the published literature. Total infection rate reached 10.7%, primary antibiotic therapy was administered in 221 cases (13.9%) and secondary antibiotic therapy in 20 (1.3%) cases. Observed infection rate of punctured wounds and wounds greater than 3 cm was 3 times higher than for all other wounds. Our findings need to be proven in further prospective clinical trials.

Epidemiology of traumatic brain injury in Austria

SummaryBackgroundTraumatic brain injury (TBI) is an important cause of preventable deaths. The goal of this study was to provide data on epidemiology of TBI in Austria.MethodsData on all hospital discharges, outpatients, and extra- as well as in-hospital deaths due to TBI were collected from various sources for the years 2009–2011. Population data (number of male/female people per age-group, population of Austrian cities, towns, and villages) for 2009–2011 were collected from the national statistical office. Incidence, case fatality rate(s) (CFR), and mortality rate(s) (MR) were calculated for the whole population and for age groups.ResultsIncidence (303/100,000/year), CFR (3.6 %), and MR (11/100,000/year) of TBI in Austria are comparable with those from other European countries. We found a high rate of geriatric TBI. The ratio between male and female cases was 1.4:1 for all cases, and was 2.2:1 for fatal cases. The most common mechanism was falls; traffic accidents accounted for only 7 % of the cases. Males died more frequently from traffic accidents and suicides, and females died more frequently from falls. CFRs and MRs increased with increasing age. CFRs were higher in patients from less populated areas, and MRs were lower in cases who lived closer to hospitals that admitted TBI.ConclusionsThe high rate of geriatric TBI warrants better prevention of falls in this age group.ZusammenfassungZiel der StudieSchädelhirntraumen (SHT) sind eine relevante Ursache von potentiell verhinderbaren Todesfällen. Das Ziel der Studie war, Daten zur Epidemiologie des SHT in Österreich zu erheben.MethodikAngaben zu SHT-bedingten Spitalaufnahmen und Ambulanzbesuchen sowie zu präklinischen und innerklinischen Todesfällen für die Jahre 2009–2011 wurden von verschiedenen Institutionen zur Verfügung gestellt. Angaben zur Bevölkerung (Geschlechtsverteilung, Altersgruppen, Einwohnerzahlen der österreichischen Gemeinden) der Jahre 2009–2011wurden von der Webseite der „Statistik Austria“ heruntergeladen. Inzidenz, Letalität, und Mortalität wurden für die gesamte Population sowie für Altersgruppen errechnet.ErgebnisseInzidenz (303/100.000/Jahr), Letalität (3,6 %), und Mortalität (11/100.000/Jahr) des SHT in Österreich entsprechen den Werten, die für andere europäische Länder erhoben wurden. Auffällig war die hohe Anzahl von geriatrischen SHT-Fällen. Das Verhältnis zwischen männlichen und weiblichen Fällen betrug 1,4:1 insgesamt, und betrug 2,2:1 in Fällen mit letalem Ausgang. Der häufigste Unfallmechanismus war Fall/Sturz; Verkehrsunfälle machten nur 7 % der Fälle aus. Männer verstarben häufiger durch Verkehrsunfälle und Selbstmorde, Frauen verstarben häufiger durch Fall/Sturz. Letalität und Mortalität nahmen mit zunehmendem Alter zu. Die Letalität war höher bei Patienten aus Regionen mit geringer Bevölkerungsdichte. In Regionen mit einem Krankenhaus, das SHT-Fälle versorgt, war die Mortalität niedriger als in Regionen ohne solches.SchlussfolgerungenDie hohe Rate an SHT-Fällen durch Fall/Sturz bei geriatrischen Patienten legt nahe, dass hier Präventionsmaßnahmen dringend erforderlich sind.

Barbiturates Use and Its Effects in Patients with Severe Traumatic Brain Injury in Five European Countries

The guidelines for management of traumatic brain injury (TBI) recommend that high-dose barbiturate therapy may be considered to lower intracranial pressure (ICP) that is refractory to other therapeutic options. Lower doses of barbiturates may be used for sedation of patients with TBI, although there is no mention of this in the published guidelines. The goal of this study was to analyze the use of barbiturates in patients with severe TBI in the European centers where the International Neurotrauma Research Organization introduced guideline-based TBI management and to analyze the effects of barbiturates on ICP, use of vasopressors, and short- and long-term outcome of these patients. Data on 1172 patients with severe TBI were collected in 13 centers located in five European countries. Patients were categorized into three groups based on doses of barbiturates administered during treatment. Univariate and multivariate statistical methods were used to analyze the effects of barbiturates on the outcome of patients. Fewer than 20% of all patients with severe TBI were given barbiturates overall, and only 6% was given high doses. High-dose barbiturate treatment caused a decrease in ICP in 69% of patients but also caused hemodynamic instability leading to longer periods of mean arterial pressure <70 mm Hg despite increased use of high doses of vasopressors. The adjusted analysis showed no significant effect on outcome on any stage after injury.Thiopental and methohexital were equally effective. Low doses of thiopental and methohexital were used for sedation of patients without side effects. Phenobarbital was probably used for prophylaxis of post-traumatic seizures.

Traumatic brain injuries caused by traffic accidents in five European countries: outcome and public health consequences

BACKGROUND Road traffic accidents (RTAs) have been identified by public health organizations as being of major global concern. Traumatic brain injuries (TBIs) are among the most severe injuries and are in a large part caused by RTA. The objective of this article is to analyse the severity and outcome of TBI caused by RTA in different types of road users in five European countries. METHODS The demographic, severity and outcome measures of 683 individuals with RTA-related TBI from Austria, Slovakia, Bosnia, Croatia and Macedonia were analysed. Five types of road users (car drivers, car passengers, motorcyclists, bicyclists and pedestrians) were compared using univariate and multivariate statistical methods. Short-term outcome [intensive care unit (ICU) survival] and last available long-term outcome of patients were analysed. RESULTS In our data set, 44% of TBI were traffic related. The median age of patients was 32.5 years, being the lowest (25 years) in car passengers. The most severe and extensive injuries were reported in pedestrians. Pedestrians had the lowest rate of ICU survival (60%) and favourable long-term outcome (46%). Drivers had the highest ICU survival (73%) and car passengers had the best long-term outcome (59% favourable). No differences in the outcome were found between countries with different economy levels. CONCLUSION TBI are significantly associated with RTA and thus, tackling them together could be more effective. The population at highest risk of RTA-related TBI are young males (in our sample median age: 32.5 years). Pedestrians have the most severe TBI with the worst outcome. Both groups should be a priority for public health action.

Outcome of brain trauma patients who have a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils in the field.

Objective To investigate the outcome of brain trauma patients who had a Glasgow Coma Scale score (GCS) of 3 and bilateral fixed and dilated pupils (BFDP) in the field. Methods Between January 2001 and December 2005, 13 European centres enrolled patients with severe brain trauma. Data sets of all patients who had a GCS of 3 as well as BFDP were analysed. Patients were classified according to the Glasgow Outcome Scale, 12 months after trauma as ‘good’ (Glasgow Outcome Scale of 5 or 4) or ‘poor’ functional recovery; relevant data for these two groups were compared. Variables that showed differences in univariate analyses (χ2 and Wilcoxon–Mann–Whitney tests) were then used as covariates in logistic regression models. A P value of less than 0.05 was considered significant. Results Ninety-two (7.8%) of 1172 patients had a GCS of 3 and BFDP; eight had ‘good’, 84 had ‘poor’ recovery. We found no significant differences in sex (79% male), age (median 32 years), and trauma mechanisms. Trauma was significantly less severe, probability of survival significantly higher (0.48 vs. 0.23) in the ‘good’ group. Only one of 39 patients who had closed basal cisterns on the first computed tomography scan, and none of the patients with midline shift greater than 15 mm had good outcomes. Logistic regression revealed that age, trauma severity, and status of basal cisterns on the first computed tomography scan were the factors determining outcomes. Conclusion Patients with a GCS of 3 and BFDP in the field should be resuscitated aggressively, especially if the trauma seems to be not too severe.

Epidemiology and Patterns of Transport-Related Fatalities in Austria 1980–2012

Objectives: Transport-related accidents remain the largest single cause of death among people aged 15 to 29 in the European Union, and despite the decrease in number of fatalities from 1990 onwards they remain a significant public health problem. The aim of this article was to analyze the long-term trends and patterns of transport-related fatalities, identify the anatomic distribution of most significant injuries in different road users, and identify the primary populations at risk of transport-related death in Austria between 1980 and 2013. Methods: Data on transport-related fatalities based on death certificates were obtained from Statistics Austria for the analyzed period. Crude and age-standardized mortality rates per 100,000 were calculated and broken down by age, gender, and month of death, and the anatomic distribution of most significant injuries were identified. Potential years of life lost before age 75 (PYLL-75) were used as a measure of public health impact. Results: A total of 39,709 transport-related fatalities were identified for the studied years; 74% were males and the mean age was 42.1 years (range 0–103). A decrease in the number of fatalities (from 2018 in 1980 to 554 in 2012), mortality rates (from 26 in 1980 to 7 in 2012), and PYLL-75 (from 68,960 in 1980 to 14,931 in 2012) was observed. Introduction of major prevention milestones (compulsory use of seat belts or child restraints) may have contributed to this decrease. Men 16–24 years old were at the highest risk of transport-related death. Pedestrian victims were more likely to be women and car drivers and motorcyclists were more often men. Most fatal transport accidents occurred between the months of May and October and prevailingly in towns of fewer than 20,000 inhabitants. Injuries to the head were the most significant injuries in all user groups (>50% of cases in all road user types). Reduced mortality rates could translate into higher prevalence of long-term disabilities in survivors of transport accidents. Conclusions: Despite the decreasing trend observed, transport-related fatalities remain a serious public health issue in Austria. An increase in the mortality of motor vehicle drivers warrants more preventive action in this group. Further research is needed on other outcomes of transport accidents such as long-term disabilities to elucidate the true public health burden of transport accidents.

Alterations of the biomarker S-100B and NSE in patients with acute vertebral spine fractures.

BACKGROUND CONTEXT Although several publications concerning the use of the biomarkers S100B and neuron-specific enolase (NSE) in vertebral spine fractures in animal experimental studies have proven their usefulness as early indicators of injury severity, there are no clinical reports on their effectiveness as indicators in patients with spinal injuries. As these biomarkers have been examined, with promising results, in patients with traumatic brain injury, there is a potential for their implementation in patients with vertebral spine fractures. PURPOSE To investigate the early serum measurement of S100B and NSE in patients with vertebral spine fractures compared with those in patients with acute fractures of the proximal femur. STUDY DESIGN Prospective longitudinal cohort study. PATIENT SAMPLE A cohort of 34 patients admitted over an 18-month period to a single medical center for suspected vertebral spine trauma. Twenty-nine patients were included in the control group. OUTCOME MEASURES S100B and NSE serum levels were assessed in different types of vertebral spine fractures. METHODS We included patients older than 16 years with vertebral spine fractures whose injuries were sustained within 24 hours before admission to the emergency room and who had undergone a brief neurologic examination. Spinal cord injuries (SCIs) were classified as being paresthesias, incomplete paraplegias, or complete paraplegias. Blood serum was obtained from all patients within 24 hours after the time of injury. Serum levels of S100B and NSE were statistically analyzed using Wilcoxon signed-rank test. RESULTS S100B serum levels were significantly higher in patients with vertebral spine fractures (p=.01). In these patients, the mean S100B serum level was 0.75 μg/L (standard deviation [SD] 1.44, 95% confidence interval [CI] 0.24, 1.25). The mean S100B serum level in control group patients was 0.14 μg/L (SD 0.11, 95% CI 0.10, 0.19). The 10 patients with neurologic deficits had significantly higher S100B serum levels compared with the patients with vertebral fractures but without neurologic deficits (p=.02). The mean S100B serum level in these patients was 1.18 μg/L (SD 1.96). In the 26 patients with vertebral spine fractures but without neurologic injury, the mean S100B serum level was 0.42 μg/L (SD 0.91, 95% CI 0.08, 0.76). The analysis revealed no significant difference in NSE levels. CONCLUSIONS We observed a significant correlation not only between S100B serum levels and vertebral spine fractures but also between S100B serum levels and SCIs with neurologic deficit. These results may be meaningful in clinical practice and to future studies.

Long-Term Trends and Patterns of Fatal Traumatic Brain Injuries in the Pediatric and Adolescent Population of Austria in 1980–2012: Analysis of 33 Years

Traumatic brain injuries (TBIs) are of special concern in the pediatric and adolescent population because of high incidence, mortality, and potential years of life lost (PYLL). Knowledge on causes and mortality trends is essential for effective prevention. The aim of this study was to analyze the long-term trends and causes of TBI-related mortality between 1980 and 2012 in the pediatric and adolescent populations of Austria. Death certificate data on TBI-related deaths of children and adolescents 0-19 years of age and exact population numbers were obtained from the Austrian Statistical Office. Five age groups were created. Mortality trends and causes of TBI were analyzed. PYLL were used to indicate the public health impact. Of 5319 identified TBI-related deaths, 75% were male victims. The annual mortality rates per 100,000 between 1980 and 2012 decreased from 25 to 2.6 in males, from 8.5 to 1.0 in females, and from 16.9 to 1.8 in the total population. Those 15-19 years of age had the highest mortalities, followed by 0-2 years of age. Over 80% of deaths were caused by accidents, inflicted TBIs were most common in those 0-2 years of age, and traffic accidents in those 15-19 years of age. In the studied period, 295,793 PYLL could be attributed to TBIs. Measures to prevent traffic accidents contributed significantly to the decrease of mortality and PYLL, especially in 15- to 19-year-old men. Causes and trends of TBI-related mortality exhibit age-group-specific patterns, and this knowledge could contribute to planning further preventive action to reduce TBI fatalities in the studied population.